Health Promotion and Maintenance
14. A client is admitted in early labor. The client requests to ambulate to enhance the strength of her contractions. Which event should prompt an RN to return the client to bed and evaluate her condition?
Health Promotion and Maintenance
14. A client is admitted in early labor. The client requests to ambulate to enhance the strength of her contractions. Which event should prompt an RN to return the client to bed and evaluate her condition?
. Intense pressure at the peak of contractions.
. Warm flushed skin.
. Nausea during contractions.
. Contractions that are mild and last 60 seconds in duration.
Test-Taking Tip
Consider the reason for reevaluating the client. Eliminate responses that are common to all clients in labor, such as skin flushing and nausea, and are not specific to this client's condition.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is correct because intense pressure at the peak of contractions may indicate the client is completely dilated and is close to delivery. A return to bed and a vaginal examination are needed to confirm this possibility. Answer 2 is incorrect because warm flushed skin is a common finding during labor and is not indicative of a need for reevaluation. Answer 3 is incorrect because nausea during contractions is a common finding during labor and is not indicative of a need for reevaluation. Answer 4 is incorrect because contractions that are mild will probably not result in cervical change; therefore, this finding does not require a reevaluation.